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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 800 E MAIN STREET-STOCKTON OA 95202-(209(668-3620 <br /> NON-REFUNDABLE PERMIT CALL 209 953.7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> JIMADDRESS 5116 L� e-rRT HWY 12 cmzP Lod( 4'5iY2- '/ � <br /> CROSS STREET PLdJL- r-�r y g�APIN DSS-ILO-�]� PARCEL SUE /I-f-k po <br /> OWNERNAME PHONE 32*1 'ZIIZ R <br /> OWNER ADDRESS SAT"\E n ft?:ID VC C"/STATE21P LDO'[ CA G <br /> CONTRACTOR WEST CA)AST %%ACKHUE HJ L PHONEIn <br /> CANTRACTORADBNESS P't' 9,01 332 r� -1 CIn/STATE21P \JIC1Uf CA CYISLS� ^ <br /> LICENSE QC42 ❑436 OTHER A NUMBER U S 1 EKRRATON DATE ZyZ r <br /> WATER TABLEDWIN: fl GEWMPHICAL INPORMATION: COOrtlIRatPo X Y L <br /> =PE=EST I'— <br /> RC <br /> BUILDING PERMIT# -O O LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION ❑ REPAWIADOITON ❑ ENDINEER DESIGNED IALTERNATIfE <br /> ❑ REPIACEMENT ❑ OUT-OF-SERVICE SEPTIC SYSTEM ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE 8�COMMERCIAL ❑ OTHER JJ <br /> ,J NUMBER OF LIVING UNrtS: Cf NUMeEROFEEOROOMS: L7 NUMBER OF EMPLOYEES: l -; <br /> 01 SEPTIC TANK TYPE/MFG P4L \IOU CAPACITY \ZOD gal #OFCONPARIMENTS <br /> ❑ GREASE TRAP TYPE/MF, CAPACITY gel #OFCOMPARTMEN7E S <br /> DISTANCE TO NEAREST: WELL R FOUNDATION it PROPERTYLINE % L-C• <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKGTXPLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> N <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES tt <br /> DISTANCE TO NEAREST WELL itFWNOATION ft PROPERTY LME ft <br /> Rr FILTERIBED WIDTH �73//j- ft LENGTH. �i . !; ft DEPTH It <br /> DISTANCE TO NEAREST WELL IOU 'V it FOUNDATION J it PROPERTY LINE <br /> ❑ MOUNDED WIma ft LENGTH If DEPTH R <br /> DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTYUNE % <br /> ❑ SUMPS WIDTH % LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION R PROPERTY UNE It <br /> ❑ DISPOSALPONDS WIDTH ft LENGTH It DEPTH ft <br /> DISTANCE TO NEAREST WELL It FOUNDATION It PROPERTY UNE fl <br /> ❑ SEEPAGE PITS NUMBER _ WETN ft DEPTH ft <br /> DWANCETONEAREST WELL If FOUNDATION ft PROPEFttt L, 'R <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, <br /> STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> BIONFD `� <br /> TITLE 'PCEJb%V`N T DATE 1\ I-L"LOtO <br /> Z4z` F <br /> d- r <br /> I <br /> I <br /> 2 I Y ME 4T <br /> I <br /> fos <br /> oWc un. <br /> T <br /> p _D-F,PA iME S � - <br /> Applkaticn Accept/EC Data Z r0 Area Employee ID# <br /> Final lnapEC:nil q' Date /�2'j /o ❑ SPECIAL PERNR-Approved by <br /> Character of Soli to CE hof 3 Ft- —r Pit/Sump Sol]Cha acter: <br /> COMMENTS <br /> PE SC Racoived heck#/ Amount PelmIt/ <br /> Code IAPOSC 9mltted Date ServieeR t# Imdu# P#ImNID# <br /> 2!62s0 JAW lb-1752s-OV 11 r s1e-Dafof 9 <br /> 42-01 ONSDE WASTEWATER TRTNINT SYSTEM PERMIT <br /> BR1/10 <br /> Ifth- <br /> I <br />